Music as medicine for the
mind and body is an ancient concept. Apollo, the Greek god of mythology, was
the giver of medicine and music. While there has been for centuries an
appreciation of the benefits of music for those who are ill, it is only in recent
years that this benefit has been more scientifically studied. Music has been
shown to affect physical, emotional, cognitive and social needs of individuals
of all ages.

Music has been
of beneficial effect on patients' experience of pain,1 allaying preoperative
anxiety in children,2 acting on the autonomic nervous system by reducing
heart rate, blood pressure and pain postoperatively,3 and having
a positive effect after acute myocardial infarction.4 Music reduces
anxiety and pain following open-heart surgery in adults.5 In a study
of pain following abdominal surgery, the introduction of both relaxation and
music was effective in reducing the degree of pain.6 Music's effect
in blunting pain works through the gate-control theory of pain by acting as
a competing stimulus that distracts the patient and directs the patient's attention
away from the pain, thus modulating noxious stimuli. Imaging studies of the
brain have shown activity in the auditory pathway, auditory cortex and limbic
system in response to music. Music has been shown to lower increased stress
levels and, with certain types of music, such as meditative or slow classical,
to produce a reduction in neurohormonal markers of stress. Music has been found
to lessen confusion and delirium in elders undergoing elective knee and hip
surgery.7 Music is also helpful in reducing patients' mood distress
when undergoing high dose therapy with autologous stem cell transplantation.8

Recently, Bernardi
et al.9 studied the cardiovascular, cerebrovascular and respiratory
changes induced by different types of music in musicians and nonmusicians. In
this study, slow (tempo) or meditative music produced a relaxing effect with
a reduction in heart rate, blood pressure, and ventilation, with raga music
producing the greatest decrease in heart rate. On the other hand, increasing
the speed (tempo) of the music can produce an arousal effect, which would increase
breathing rate, blood pressure and heart rate due to sympathetic activation.
Auditory inputs, such as prayer or yoga mantra carried out with rhythmic repetition,
can modify cardiorespiratory function. In the case of music, it is the ability
of music tempo to affect the heart rate or circadian rhythms and entrain breathing
frequency proportionate to the tempo of the music. In the study by Bernardi
et al., it is of interest to note that a pause provided after a musical piece
was played led to the greatest evidence of relaxation and cardiovascular benefit.

The study by Hatem
et al.10 in this issue of the Jornal de Pediatria on the therapeutic
effects of music in children following cardiac surgery is an important contribution
to an appreciation of the potential benefits of music in controlling pain and
anxiety and moderating vital signs. In the study, the authors were able to demonstrate
significant changes in reduction of pain, heart rate and respiratory rate. While
postoperative pain is routinely managed with pharmacological agents, the addition
of non-pharmacological agents is important because of its potential for reducing
drug doses and side effects. Postoperative pain can exacerbate the child's stress
and contribute to a difficult postoperative course. Helping to control the pain
and anxiety, often interrelated, can provide a more optimal postoperative course.
The authors of the study recognize that the results are potentially affected
by the sample size and the non-randomization by age group. Also, an observer,
as opposed to the child's participation, performed the analysis of the pain
scale, which may affect the validity of this assessment. The effect of other
factors, such as cardiovascular sedative drugs, while not altered during the
30-minute experiment, could nevertheless have some impact, depending on the
timing of the drugs prior to the study.

In optimizing the
benefits of music, we need to recognize that while this modality can be effectively
provided in a passive manner, as in the study by Hatem et al., its effects can
be enhanced by the participation of a music therapist. Music therapists integrate
their technique into the care of cardiac patients, assisting them with coping
with the stress of the illness. This integration considers the age, sex and
cultural background of the patient, amongst other variables.11 In
studies comparing passive listening to the participation of a music therapist,
the latter has always been found to be more advantageous. In the study by Hatem
et al., a single piece of music (Spring, from Vivaldi's Four Seasons) was played.
With music therapy, the individual's previous musical experience is considered
to optimize the choice and tempo of music. In this study, too, the children
in the control group had headphones attached without music. Headphones may help
by masking the intense disrupting sounds common in the intensive care unit and
contribute to reduction in stress. However, the validity of this control without
music is open to question.

Hatem et al. have contributed
to our understanding of the importance of the introduction of music to the intensive
care unit in optimizing patient care by providing pain relief, allaying stress,
and reducing sympathetic activity. We need to recognize that music is an important
and humane addition to the care of children post-cardiac surgery.

On a personal note, for
the past few years, we have had a harpist in our pediatric intensive care unit
at Massachusetts General Hospital helping to calm not only the patients, but
also the families, who often have responded very positively. In addition, the
nursing and physician staffs have told me how much the harpist's playing has
helped to calm them too!

9. Bernardi
L, Porta C, Sleight P. Cardiovascular, cerebrovascular, and respiratory
changes induced by different type of music in musicians and non-musicians:
the importance of silence. Heart. 2006;92:445-52.